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CHOLEDOCHOLITHIASIS: POSTOPERATIVE MANAGEMENT
		B Millat, MD , Hôpital Saint Éloi , Montpellier, France B Malassagne, MD, PhD , Hôpital Henri Mondor, Université Paris XII, Créteil, France
1. Results 2. T-tube or primary closure? 3. Stone clearance control 4. References		1. Results of laparoscopic common bile duct exploration The success rate of laparoscopic CBD stone extraction has increased over the years from 22% in 1991-4 to 87% in 1995-7 ( Hyser et al. , 1999 ). More recently, success rates of 97% ( Keeling et al. , 1999 ) and 98 % ( Martin et al. , 1998 ) have been reported. Results presented in the literature may be analyzed through 24 published series involving 2340 patients with CBD stones treated by laparoscopy ( French Association of Surgery / Gayral and Millat, 1999 ). In a global analysis, 68% of CBD stones are extracted using a transcystic approach and 31% by choledochotomy. Postoperative morbidity ranges from 5% to 10% after a transcystic approach and from 5% to 18% after choledochotomy. Complications related to the transcystic approach are cystic duct or CBD injuries. Complications related to choledochotomy are T-tube dislodgement and the occurrence of biliary fistulae when primary closure is performed. Re-operation is required in 0 to 2.5% of cases. Postoperative collections are treated by percutaneous drainage. Among the 2340 patients, the reported postoperative mortality is 0.6% (range: 0 to 4%). Rates of residual stones after treatment are difficult to assess, since some residual stones are not symptomatic. The approximate rate of residual stones is estimated from 3% to 5%. Hospital stay varies dramatically according to the individualized practice where the patient is hospitalized. Transcystic extraction and primary closure of choledochotomy significantly reduces hospital stay.
1. Results 2. T-tube or primary closure? 3. Stone clearance control 4. References		2. T-tube or primary closure following choledochotomy? Morbidity related to the T-tube includes: bacterial colonization of the biliary tract; septic complications following T-tube cholangiography; electrolyte disturbances; accidental dislodgement or obstruction; rupture at removal; bile peritonitis after removal; incisional abscesses. During the open cholecystectomy era, results of three randomized studies showed that a primary CBD closure significantly lowered morbidity due to: reduced sepsis ( Lygidakis, 1986 ) ; less postoperative discomfort; reduced costs ( Sheen-chen et Chou, 1990 ) ; a shorter hospital stay ( Williams et al. , 1994 ). Despite demonstrations by Croce and more recently Martin ( Croce et al., 1996; Martin et al., 1998 ) of the safety and feasibility of laparoscopic primary closure of the CBD, no randomized study comparing primary closure to drainage has yet been reported. A 5.5% complication rate related to the presence of the T-Tube has been reported ( Millat et al., 1995; Millat et al., 1996 ). Re-operations for dislodged T-tubes have also been reported ( Stoker, 1995 ). Indications for primary closure are: CBD stone clearance which requires verification by intraoperative cholangiography or choledochoscopy; sphincter permeability; a high quality suture approximation of non-inflamed CBD walls; absence of severe cholangitis. In order to avoid a higher complication rate and a longer postoperative hospital stay resulting from the use of T-tubes, DePaula et al., 1994 ) described internal biliary drainage with a 7 French endoprosthesis instead of external T-tube drainage. The technique provides adequate emptying of the CBD, a rapid decrease in bilirubin levels, safety regarding the primary suture of the CBD, and simplicity. However, a postoperative upper endoscopic procedure is required to remove the endoprosthesis. In addition, postoperative radiologic control of the biliary tract is only possible after a new endoscopic cholangiography ( DePaula et al., 1994 ).
1. Results 2. T-tube or primary closure? 3. Stone clearance control 4. References		3. Control of CBD stone clearance The absence of residual stones in the CBD is checked one week after surgery by cholangiography through the T-tube. This cholangiography must be performed under low pressure and should indicate: the absence of stones; good duodenal passage under low pressure; and a complete cholangiogram. Prophylactic antibiotic therapy is recommended. If complete stone clearance is confirmed, the T-tube is clamped and removed 21 days after surgery without anesthesia. If residual CBD stones are detected, they are best treated by endoscopic sphincterotomy (ES).
1. Results 2. T-tube or primary closure? 3. Stone clearance control 4. References		4. References Croce E, Golia M, Azzola M, Russo R, Crozzoli L, Olmi S et al. Laparoscopic choledochotomy with primary closure. Follow-up (5-44 months) of 31 patients. Surg Endosc 1996;10:1064-8. DePaula AL, Hashiba K, Bafutto M. Laparoscopic management of choledocholithiasis. Surg Endosc 1994;8:1399-403. Gayral F, Millat B, rédacteurs. Lithiase de la voie biliaire principale. Rapport présenté au 101 e congrès Français de Chirurgie. Monographies de l’Association Française de Chirurgie; 1999 Oct 7-9; Paris, France: Arnette;1999. Hyser MJ, Chaudhry V, Byrne MP. Laparoscopic transcystic management of choledocholithiasis. Am Surg 1999;65:606-9; discussion 610. Keeling NJ, Menzies D, Motson RW. Laparoscopic exploration of the common bile duct: beyond the learning curve. Surg Endosc 1999;13:109-12. Lygidakis NJ. Hazards following T-tube removal after choledochotomy. Surg Gynecol Obstet 1986;163:153-5. Martin IJ, Bailey IS, Rhodes M, O'Rourke N, Nathanson L, Fielding G. Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg 1998;228:29-34. Millat B, Deleuze A, Atger J, Briandet H, Fingerhut A, Marrel E et al. [Treatment of common bile duct lithiasis under laparoscopy. A prospective multicenter study in 189 patients]. Gastroenterol Clin Biol 1996;20:339-45. Millat B, Fingerhut A, Deleuze A, Briandet H, Marrel E, de Seguin C et al. Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis. Br J Surg 1995;82:1266-9. Sheen-Chen SM, Chou FF. Choledochotomy for biliary lithiasis: is routine T-tube drainage necessary? A prospective controlled trial. Acta Chir Scand 1990;156:387-90. Stoker ME. Common bile duct exploration in the era of laparoscopic surgery. Arch Surg 1995;130:265-8; discussion 268-9. Williams JA, Treacy PJ, Sidey P, Worthley CS, Townsend NC, Russell EA. Primary duct closure versus T-tube drainage following exploration of the common bile duct. Aust N Z J Surg 1994;64:823-6.